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vaccination the proportion of hospital cases was 2% forthe vaccinated and 57% for the controls. The lowinuitience of respiratory disease in the naval recruitswas ascribed to penicillin prophylaxis, since the incidenceof streptocoecal infection was low. During a comparableperiod in 1954, when no penicillin was given, streptococciwere iolated from 50% of cases of respiratory diseasein the camp.

Infliienza vaccine was also used in both the militaryand naval recruits. In the army study the group vac-. mated against influenza received no adenovirus vaccine.Thew had a similar incidence of respiratory disease to:he unvaceinated controls.

1. Sunshine, I., Leonards, J. R. Proc. Soc. exp. Biol., N.Y. 1954,86, 638.

2. Berman, L. B., Jeghers. H. J., Schreiner, G. E., Pallotta, A. J.J. Amer. med. Ass. 1956, 161, 820.

3. Goldbaum, L. R. Analyt. Chem. 1952, 24, 1604.

HÆMODIALYSIS FOR BARBITURATE POISONING

THE method of haemodialysis offers a rational meansof treating barbiturate intoxication by removing thepoison from the body. Experimental work in dogs 1showed that haemodialysis could remove up to 40% ofan invested dose of phenobarbitone from the body, andrather smaller amounts of the shorter-acting barbiturates.Berman et al.2 have successfully treated 8 patients withbarbiturate poisoning by this method. An essential

part of their regime is the repeated determination, byspectrophotometry, of the plasma level of barbiturate.3One of Berman et al.’s patients took the incrediblequantity of 25 g. of phenobarbitone. When admittedto the special unit forty-nine hours later she was deeplycomatose and had a blood-barbiturate level of 253 mg.per 100 ml. It is a testimony to this treatment that sherecovered, for it is very unlikely that conventionalmethods could have saved her life. After six hours ofdialysis the blood-barbiturate level fell to 11-4 mg. per100 ml. and the patient recovered consciousness. Buta further rise in the barbiturate level followed, and twomore dialyses were required before recovery was com-plete. Other cases in this series show that dialysis canreduce the blood-level of barbiturates, and can hastenthe return of consciousness, after poisoning by pheno-barbitone, barbitone, amylobarbitone, and the short-actinr barbiturates. Haemodialysis was most effectiveafter poisoning by phenobarbitone, and when the blood-level of the drug was high.The technique of dialysis is complex, and not without

hazards of its own ; but results such as these suggestttut it may come to have an important place in thetreatment of severe barbiturate poisoning.

HUMANISTS AND SCIENTISTS

PHILOSOPHY has tended to become a specialismong other specialisms, and many philosophers seem; hf men who cultivate a particularly tidy way of talkingbout ways of talking." In Prof. James Drever’s estimate,

is one of the reasons why the humanist argues against. cientific study of human behaviour and why he:plains about the uses to which psychological know-

has been put. It is not so much the presumption‘ ience which offends him as the abdication of philo-

Professor Drever was addressing the Sheffieldting of the British Association last week. He

tured the humanist pointing resolutely back into thePlato may help here, Rousseau there. " Every-

’- r..; worth saying has already been said, and the aim’ ucation is to teach the young where they may"! But, Professor Drever observed, a man makingporary decisions wanted contemporary guidance,

.-. Tiett was where scientists were apt to be forced into

. tion where they did not belong. The scientist couldther well in dealing with means and consequences ;

perhaps he could give advice about ends as well. Butin the latter field the scientist had no special credentials ;and the humanist might be right to resent the undueconsideration sometimes given to what his scientificcolleague had to say on general matters. ProfessorDrever suggested that the remedy lay with the humanisthimself. He should attempt to recapture the broadinsight and speculative boldness of his predecessors." He might not measure up to Plato, but at least he coulddo better than Monsieur Poujade or Joe McCarthy."The task of acquiring insight and speculative boldnesswas harder now than it had ever been, but it was alsomore important. If the humanist had something worthwhile to say, ordinary men would listen, but some of theothers might be a trial. He must have an answer when theprofessional philosopher asked " Just what do you meanwhen you say that X is better than Y

"

1. Gillman, T., Penn, J., Bronks, D., Roux, M. Brit. J. Surg, 1955, 43,141. Gillman, T., Penn, J. Medical Proceedings (Johannesburg),1956, 2, 93.

2. Gillman, T., Penn, J., Bronks, D., Roux, M. Lancet, 1955, ii,945.

3. Williamson, P. Ibid, 1956, i, 206.

CLOSURE OF WOUNDS

THE primary closure of skin wounds, whether surgicalor traumatic, has interested surgeons for at least 35centuries. During the long ages when no suture materialwas sterile and sepsis was inevitable, various attemptswere made to close wounds without inserting stitches.The author of the Edwin Smith Papyrus, dealing withthis subject in 1600 B.C. (or thereabouts), wrote : " Ifthou findest a wound open, thou shouldst draw togetherfor him its gash with two strips of linen over that gash."An ingenious and less remote method, popular in the 19thcentury, was to transfix both wound margins by a straightneedle, and hold the edges in contact by thread appliedexternally as a figure-of-eight.

Recently Gillman and his colleagues 1 have examinedclinically and histologically the processes of primaryhealing, and, as a result, they became dissatisfied withthe results of orthodox suturing. They found that theregenerating epithelium along the wound margins grewdown towards the dermis, even when the wound wascarefully sutured, and they regard this invasion of thedermis as " a consistent phenomenon in uncomplicatedrepair of cutaneous wounds." They also drew attentionto the harm done by the actual stitches because of asimilar epidermal downgrowth. Their tests on humanvolunteers involved making incised wounds on the fore-arm, where, incidentally, there is scanty subcutaneoustissue and skin margins are notoriously liable to invert.Having convinced themselves that sutures are less

efficient and more harmful than is generally believed,Gillman et al. adopted an alternative technique-theclosure of incised wounds with narrow strips of adhesiveplastic tape.2 Pieces of ordinary stationery plastic tapeare used, unsterilised. They are 21/2-3 in. long and1/4 in. wide, and they are applied with narrow gapsbetween them, the wound edges being squeezed togetherto give good apposition. Gillman et al. say that " speedierand much better apposition of incised edges " is achievedby this method, and they propose " discarding suturesentirely for skin closure whenever possible," even in

major operations. Williamson 3 has also had verysatisfactory results with a similar method.

Before these conclusions can be fully accepted, furtherresearch will clearly be needed. Comparisons will haveto be made between the new method and the best effortsof skilled surgeons using orthodox techniques. Mean-while, there remains for all surgeons an unaltered obliga-tion to close wounds with such care that the result is,by the highest standards, inconspicuous and surgicallysound. Fashions will change, but at present there is nobetter routine method of proven value than to use the

504

fine,st needles and suture materials ; to insert if necessaryas many as eight stitches to the inch ; and to achieve

proper eversion without too much tension. In certainareas, such as forehead, eyelids, or neck, subcuticularsutures of wire or other material may give better results,since there is no need for early removal to avoid stitchmarks. All these methods take time, but it would be apity if any well-tried technique, widely applicable andhighly reliable, was discarded because it made consider-able demands on a surgeon’s patience or craftsmanship.

1. Hornkiewytsch, T., Stender, H. S. Fortschr. Röntgenstr. 1953,79, 292.

2. Hagedorn, H. Die Med. 1953, 2, 1693.3. Ward, M. W. P. Lancet. 1954, 1, 887.4. Lindblom, L. A. Svenska Läkartidn. 1955, 52, 4880.5. Batt, R. C. Radiology, 1955, 65, 926.6. Wickbom, I. G., Rentzhog, U. Acta radiol., Stockh. 1955, 44,

185.7. Wise, R. E., O’Brien, R. G. J. Amer. med. Ass. 1956, 160, 819.8. Jordan, P. H. jun. Surg. Gynec. Obstet. 1956, 102, 218.9. Twiss, J. R., Beranbaum. S. A., Gillette, L., Poppel, M. H.

Amer. J. med. Sci. 1954, 227, 372.

CHOLECYSTANGIOGRAPHY

’EXPERIENCE in the use of the intravenous contrastmedium, sodium iodipamide (’ Biligrafin,’ ’ Cholografin ’),for the display of the biliary tract has been accumulatingin the past three years, and clearer ideas of its uses andvalue are beginning to emerge. For the demonstrationof the gall-bladder it is obviously superior to media givenby mouth when the patient is vomiting or when absorp-tion is impaired by diarrheea ; and it has another clearadvantage when an early answer is wanted, as in acuteabdominal conditions. On the other hand, though nodeaths have been reported after its use, it has given riseto severe reactions.l-5 Moreover, it is a more time-

consuming and troublesome procedure for the radio-

logist and his staff ; and it also has the theoretical

disadvantage that it is concentrated in the liver, thusgiving poorer evidence of gall-bladder function than theoral media, which are largely concentrated in the gall-bladder itself. It seems undesirable, therefore, to usebiligrafin when oral media will suffice.Most authors agree that in the routine investigation of

the gall-bladder, oral cholecystography is still the methodof first choice, and that intravenous cholecystographyshould follow only when there are clear indications for it.It is not indicated after a normal oral cholecystogram,which practically excludes gall-bladder disease,6 unlessthe particular aim is to exclude a common-duct stone ;nor is it indicated by the finding of gall-stones, againunless it is important to examine the common duct forstones. It is indicated, however, when the findings oforal cholecystography are equivocal (and that includesa shadow of poor density) and when there is completeabsence of filling. In that case, biligrafin may con-clusively demonstrate gall-stones, or it may show thebile ducts without gall-bladder filling-a finding whichreinforces the evidence of gall-bladder disease and whichis often, though not invariably, associated with stones inthe cystic duct.7 Occasionally, a gall-bladder which isnot filled by oral cholecystography fills normally withbiligrafin : it is certainly not safe to assume from thisambiguous result that the gall-bladder is normal, becauseJordan 8 has recorded 4 such instances in which chole-cystitis was found at operation.

In the investigation of the postcholecystectomypatient, however, biligrafin seems the best agent, eventhough Twiss and his colleagues 9 have shown that oralmedia can be used. In the so-called " postcholecystec-tomy syndrome

" intravenous eholangiography can

sometimes be decisive, by demonstrating stones in thecommon duct or in a cystic-duct remnant ; but suchclear-cut findings are rare. Usually the biliary systemlooks normal or shows an abnormality of doubtfulsignificance, such as a cystic-duct stump without stones.

There is both clinical and pathological evidence 10 11 tthese remnants are almost always accompanied inflammation and that their removal is beneficial. the other hand, McClenahan and his colleagues 12 fcystic-duct remnants nearly twice as often in a conseries of symptom-free patients as in a group w

postcholecystectomy pain.Similarly open to dispute is the significance of dilata

of the bile-ducts. Since the early work by Oddi on dit has been held that the bile-ducts undergo a sor

postoperative physiological dilatation ; but if maximum diameter of the normal duct (as meason the radiographs) is accepted as 8 mm.,13 14 the

is, in most cases, not abnormally dilated after ch

cystectomy. Twiss et awl. consider that dilatation, wpresent, is evidence not of physiological dilatation bu"biliary dyskinesia"; Shehadi’s view 15 is that usual cause is stenosis or fibrosis of the sphincteOddi ; and Wise and O’Brien believe that dilataindicates partial obstruction, but only when the meter exceeds 15 mm. On the other hand, Don Campbell 16 hold that all that can be inferred dilatation is that the duct has been obstructed at stage, usually in the past and by a stone, and thatdilatation has proved irreversible. They found dilducts just as commonly in symptom-free postcholecyectomy patients as in those with symptoms, and conclude that this finding in the postcholecystectsyndrome is of no significance. McClenahan et found a similar incidence of dilated ducts in symptfree patients compared with those who had pain

Stasis in the bile-ducts, measured either by the after injection at which the opaque medium startenter the duodenum or by fading of the bile-duct shaalso seems of doubtful significance in the postcholecystomy syndrome, for wide variations in these timesfound in patients both with and without symptoms.

Biligrafin provides a rough index of liver function,!this is seldom of practical value. With normal liver tion, the biliary tract will sometimes fail to opaalthough that is exceptional. With some reductioliver function, opacification is often impaired ; and severe liver damage the biliary tract can seldom be When there is jaundice due to obstruction or liver dambiligrafin is rarely successful in outlining the ducts,so it is of little value in the differential diagnosis the jaundice has cleared. In this respect biligrafin (methyl glucamine iodipamide in 50% solution), whas been recently introduced,18 promises better resultsbut even so it seems unlikely to be of value in jaundiced patients.

10. Gray, H. K., Sharpe, W. S. Proc. Mayo Clin. 1944, 19. 11. Garlock, J. H., Hurwitt, E. S. Surgery, 1951, 29, 833.12. McClenahan, J. L., Evans, J. A., Braunstein, P. W. J.

med. Ass. 1955, 159, 1353.13. Royer, M., Mazure, P., Kohan, S. Gastroenterology, 1950, 16,14. Berk, J. E., Karnofsky, R. E., Shay, H., Stauffer, H. M.

J. med. Sci. 1954, 227, 361.15. Shehadi, W. H. Radiology, 1956, 76, 7.16. Don, C., Campbell, D. H. J. Fac. Radiol. 1956, 7, 197.17. Samuel, E., Gluckman, J., Barlow, J. Lancet, 1955. i. 1318. Gaebel, E., Teschendorf, W. Fortschr. Röntgenstr. 1954, 8119. Berk, J. E., Mellins, H. Z., Brodie, M. Amer. J. med

1956, 231, 289.

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